Monday, 6 June 2011

TUBERCULOSIS: resurgence on the streets of London, after it was nearly eradicated in the 1970s

Chris Smyth : The Times June 03, 2011

English heritage skeletal remains expert Dr Simon Mays examines vertebrae from the skeleton of an Iron Age man dating back to about 300BC, believed to be the earliest case of tuberculosis found in Britain. Source: Supplied

TUBERCULOSIS has been in Britain since at least 300 BC, yet doctors are still under pressure to eradicate the disease.
The perception was that the Western world had beaten TB, or that it was a disease brought in by immigrants. But it's becoming worryingly common again, after an outbreak in the UK.
Stuart Ford's lungs are wrecked by tuberculosis. His emaciated body racked by consumptive coughing, he cuts a Dickensian figure.
A legacy of life on the streets of London, he talks with difficulty, constantly pausing for breath as he makes dark jokes through a mouth of blackened teeth.
Yet Mr Ford is not a character from a Victorian novel. He is alive - if only just - in 2011, and spoke to The Times in a hostel only a few hundred yards from the Houses of Parliament.
Tuberculosis, long thought to be conquered in Britain, is once again gaining a toehold on the same London streets where it was endemic more than a century ago.
Although TB rates have been rising for decades, many assumed that this was a result of infections brought in from abroad. Mr Ford, who has spent almost half his life homeless in the capital, proves otherwise. While immigrants still account for most cases, about one sufferer in five catches the disease in Britain, with the homeless and prisoners among the hardest hit.
Mr Ford, 42, was incredulous when doctors told him he had TB. He says his first reaction was: "But I'm English! British!" He received his diagnosis when going into hospital for methadone treatment. "Doctors looked at my lungs and took me to casualty. When I came round, everyone was wearing a mask. It was a bit of a shock," he said.
Doctors found that he had lost 75 per cent of his lung capacity to the disease. Because it had been found so late, he faced a gruelling 18 months of treatment. "I was scared shitless. They kept me in quarantine for four months. I didn't have much choice. I couldn't move. They said if you don't take your medicine, they can section you."
Mr Ford remained in hospital, suffering side-effects of fatigue and severe headaches and being given regular antibiotics. Eventually the disease was eradicated. But the damage remains.
"I lost eight stone in two months," he said. "I still don't feel great. I have trouble walking. I'm out of breath even talking for a long time. My lung age is 82. An old bloke went past me the other day. He was going faster than I was."
Mr Ford can no longer work and makes mordant jokes about his desire for a mobility scooter and sheltered housing. "There are so many things I would like to do but can't. Sometimes I can't even get out of bed in the morning. I used to swim like a fish. I can't do anything like that any more."
As well as the physical strain, there is the stigma. "Some people started to see me more like a leper."
Alistair Story, a nurse who runs Britain's only mobile TB detection unit, searching out cases by X-raying prisoners and the homeless across the South of England, says this is common.
"It's a disease of poverty and exclusion that finds a foothold on the margins of society," he said as homeless men queued up to be X-rayed. "We find a case every other week. We find people with big holes in their lungs."
He added: "The vast majority of stuff we deal with is home-grown, British TB. There is a lot of active, ongoing transmission. The evidence is irrefutable. The DNA of the organism tells us clearly that transmission is occurring in the capital. I dealt with a Somali who had TB - everyone assumed he'd brought it in. He got it in the hostel."
Rates of TB among prisoners and the homeless are around five times higher than in the general population; the effect of people congregating in substandard buildings, huddling together for warmth. Those with drug or alcohol problems are particularly vulnerable.
Many homeless people attribute the symptoms of TB to the ravages of drink, drugs and life on the street. Mr Story's "find and treat" project has a van with X-ray equipment that tours hostels and drop-in centres.
"TB usually comes at the end of a hard road," Mr Story said. "As a healthy adult your chances of getting infected are very remote. Your chest will deal with it. But their immune systems are shot to bits. Infection gets a foothold very quickly and progresses to full, active TB. And then they're in the perfect place to transmit it. They've created a perfect storm. There's an unholy alliance between compromised immunity, shared airspace and un- detected cases, and a lifestyle that masks the presentation of the disease."
Ominously, an increasing number of cases are resistant to one or more of the four main drugs used to treat TB. "It threatens to make the disease untreatable," Mr Story said.
On visits to other towns and cities, including Oxford, Banbury and Luton, he regularly finds cases among the homeless. He also screens at London's jails, which have now been forced to begin routine X-rays of new inmates. "We've never gone into a prison without finding a case of active TB," he said.
Mr Story says his unit can do nothing more than crisis managing, treating those with the disease but doing nothing about latent infections. Health authorities in London admit that they are failing to control the outbreak, never mind eradicate it, and have plans for a more aggressive approach.
After rates plunged to negligible levels in the 1970s, TB services were wound down and Mr Story said that this has left Britain unprepared to deal with a resurgence of the disease. "People have taken their eye off the ball," he said. "They thought that TB would soon be eradicated. We've been flying by the seat of our pants."

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After service in the British SAS Regiment the author became a physician and then an orthopaedic surgeon.
He has held professorial positions in Canada, Vietnam and the United States, practiced and taught orthopaedic surgery in three continents and in several wars.
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